NPIMap

Organization Active NPI

Methadone Clinic of East Texas LLC

  • Methadone Clinic
  • Tyler, TX
National Provider Identifier
1104144088
Registry record updated Sep 3, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Methadone ClinicTaxonomy code 261QM2800X
License
000039 Issued in TX
Legal business name
METHADONE CLINIC OF EAST TEXAS LLC
Practice address
1510 S Vine Ave
Tyler, TX 75701-2826
Phone
(800) 805-6989
NPI assigned
May 17, 2010
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 3, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Rupert McCormac, MD
Title
Chief Executive Officer
Phone
(800) 805-6898

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X
Multi-Specialty Clinic/Center 261QM1300X
Methadone Clinic 261QM2800X 000039 TX Primary
Primary Care Clinic/Center 261QP2300X
Substance Use Disorder Rehabilitation Clinic/Center 261QR0405X TX

Addresses

Primary practice location

1510 S Vine Ave
Tyler, TX 75701-2826

Mailing address

PO Box 749057
Atlanta, GA 30374-9057
Phone (800) 805-6989

Other identifiers 1

IdentifierTypeStateIssuer
2121550MedicaidTX

Other names 1

  • Crossroads Treatment Centers Tyler Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX
Opioid treatment program
Medicare-enrolled since Jan 1, 2020

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200116000722 TX Part B Supplier - Opioid Treatment Program (Otp) 4981039179 Practice locations: Tyler, TX

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
45D2181370Methadone Clinic of East Texas LLC Tyler1510 S Vine Ave, Tyler, TX 75701Certificate of waiverApr 1, 2028

National Provider Directory

National Provider Directory

Locations

1510 S Vine Ave
Tyler, TX 75701
Phone (903) 312-1988

536 S Oakland Ave
Tyler, TX 75702

Practitioners & affiliated clinicians

Practitioners 17

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 17

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1274054400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1725321600000",
    "number": "1104144088",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 749057",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303749057",
            "telephone_number": "800-805-6989",
            "fax_number": "864-558-8511"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1510 S VINE AVE",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757012826",
            "telephone_number": "800-805-6989"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "METHADONE CLINIC OF EAST TEXAS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-05-17",
        "last_updated": "2024-09-03",
        "certification_date": "2024-09-03",
        "status": "A",
        "authorized_official_last_name": "MCCORMAC",
        "authorized_official_first_name": "RUPERT",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "800-805-6898",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM2800X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Methadone",
            "state": "TX",
            "license": "000039",
            "primary": true
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR0405X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Substance Use Disorder",
            "state": "TX",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2121550",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crossroads Treatment Centers Tyler",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tyler, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 3, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.